EBM Founder David Eddy, PhD, MD

Business Week: Economics, Not Evidence, Rules Medicine

Imagine a CAM-IM/conventional medicine integration discussion which began not with the prevailing assertion that one is an evidence-based medicine (EBM) and the other is not. Instead, how about starting the dialogue with a reading from this Gospel according to Business Week ...

"You get paid for operating and not paid for not operating ... Conflict of interest is hard to rule out."

Jack L. Paradise, MD, U Pittsburgh School of Medicine

The May 29, 2006, edition of Business Week opens with the following cut-line: "From heart surgery to
prostate care, the health care industry knows little about which common
treatments really work." The cover story, 25 pages printed out, is
entitled "Medical Guesswork." This scathing review of the state of medicine's relationship with economics and evidence includes the following comments.

On economic factors:

"Medicine (is) making decisions with an entirely different method from what we would call rational." (David Eddy, MD, founder of Archimedes, is quoted here.)

"More troubling, many doctors hold not just a professional interest in which treatment to offer, but a financial one as well."

"You get paid for operating and not paid for not operating ... Conflict of interest is hard to rule out." (Researcher Jack L. Paradise, MD of the U Pittsburgh School of Medicine quoted.)

"There is no question that the economic vested interests of the physician enter into the decision." (Eric Klein, MD, of the Cleveland Clinic, is quoted.)

"Once a hospital installs a new catheter lab, it has a powerful incentive to refer more patients for the procedure."

"The way the US healthcare system is structured offers doctors, hospitals, and insurance companies enormous financial incentives to provide more and more care."

(Regarding Eddy's negative review of studies of outcomes of a widely-prescribed ophthamology drug) "The tom-toms sounded among all the ophthamologists ... I

"If anything, it looks like there is a
substantially increased risk of death if cared for in high-cost areas
(of the country, where the number of specialists are
high)."

Elliott S. Fisher, MD,Dartmouth Medical School

felt like Salman Rushdie." (Eddy, again.)

"The decisions to perform back surgery are a classic case of supply (the number of orthopedic surgeons in the geographic area) driving demand."

"In people with identical symptoms, operations like spinal fusions are performed 20 times as often in some
parts of the US as in others. Spinal fusion is the most variable
condition in all of medicine."

"In 1993, the federal government's Agency for Health Care Policy and Research (now
AHRQ) convened a panel to develop guidelines for back surgery. Fearing
that the recommendations would cast doubt on what doctors were doing,
a prominent back surgeon protested ... and lawmakers slashed funding to
the agency."

"The overwhelming number of heart procedures done these days do no affect a patient's life span at all." (L. David Hillis, MD, U Texas Southwestern Medical School, is quoted.)

John Wennberg, MD, MPH

"The
average numbers of days spent in the hospital during the last six
months of life are 10.1 days at Stanford University hospital compared
to 27.1 days at New York Univresity Medical Center. The average number
of doctor visits (in the last 6 months) ranged from 17.6 to 76.2, with
NYU at the top."

"The problem is not underuse in low-rate regions and hospitals but overuse and inefficiency in high rate regions." (Jack Wennberg, MD, of Dartmouth University is quoted.)

"If anything, it looks like there is a
substantially increased risk of death if cared for in high-cost areas
(of the country, where the number of hospitals and specialists are
high)." (Elliott S. Fisher, MD, of the Dartmouth Medical School, is quoted.)

"We are wasting 30% of healthcare spending on stuff with no benefit and perhaps causing harm." (Fisher, again.)

"This nation spends 2.5 times as much as any other country per person on health

"The portion of medicine that has been proven effective is still extremely low - in the range of 20% to 25%."

care. Yet middle-aged Americans are in far worse health than their British cousins."

On other evidence factors:

"The portion of medicine that has been proven effective is still extrememly low - in the range of 20% to 25%."

Regarding the prevalence of surgeries to place tubes in kids ears: "Don't just do something. Sit there." (Researcher Paradise, quoted.)

"Only in 3% of patients with severe artery disease does the bypass operation improve outcomes."

"Even when common treatments are dubious, physicians don't rush to change their practice."

"Well-informed patients (about the actual evidence and not just a physician opinion) opt for less aggressive approaches 23% less often. In some cases the drop is much bigger - 50% to 60%."

At the educational center of this feature is a 15 question Quiz entitled "Healthy Skepticism." The quiz leads off with "Americans undergo more medical treatments, both surgery and drug therapy, than anybody else on the earth. Are we better off as a result? Not necessarily. Take our quiz and see how the U.S. stacks up in some important health stats." The results are not comforting.

Clearly, the "E" in the "EBM" which is currently practiced stands for "economic"not "evidence." Theevidence teaches us that we have an Economic-BasedMedicine.

Comment: Clearly, the "E" in the EBM which is currently practiced in medicine stands for "economic." That conventional medicine remains economic-based, not evidence-based, despite billions spent on research over five decades, must be accepted as a given.

The picture painted here is not pretty. And the Business Week
writers managed to spare us reference to the ugliest outcome of this pattern of economically-driven behavior: medical
intervention, following this usage, is at least the third
most influential cause of death in the US - nd may be higher. (See related IBN&R article on
medically-caused deaths.)
There is clearly an intention in some conventional circles to change this economic "E" to "evidence" in EBM. Just as clearly, there are some who will shoot the messenger rather than reform their practices. How does one respond to a systematic review and guideline which urges a radical change of clinical priorities? Well, kill the messenger, of course. Cut funding to the agency!

We see a similar split in the CAM-IM fields - though these have less ability to force suppression of evidence. Some CAM-IM providers will go with their practices and instincts - and economic interests - regardless of the "evidence." At the saem time, the last decade, in which research funding for CAM-IM has been available, shows that another set in the CAM-IM world are working hard, and despite still extremely-limited funding, to create a well-researched evidence-base for CAM-IM care choices. (See related IBN&R article on the explosion of CAM-IM research, and shrinking opportunity to be funded).

In short, we have both self-interested
ostriches and those with "EBI" - Evidence Based Intention - in both CAM-IM and
conventional camps.

In short, we have self-interested ostriches and those with "EBI" - Evidence Based Intention - in both camps.This is our actual common ground for dialogue. Mostly, we don't have much evidence. History, as captured in this Business Week feature, suggest that the dialogue is not fundamentally civil. This is hardball -- and the ball is thrown
hardest, and the intent to kill most focused, when the lie is biggest
and there is the most, economically, at stake.
There are many lessons here. One simple take home is that it is long past time to drop portraying the integration dialogue in a way that polarizes the dialogue over evidence. Business Week
opines that conventional medical doctors "cannot be blamed for the evidence not
being there." Neither can the CAM-IM advocates and practitioners. But all actors in the CAM-IM integration dialogue can and
should be blamed if they over claim that their medicine is evidence-based, particularly if, from
their glass houses, they are tossing incendiary devices.

Through what not yet practiced coalitions will we finally figure out how to respond effectively to this evidence today?

Coda: The data reported in Business Week are not new. Literature reviews have turned up this kind of evidence for nearly 30 years. A much quoted 1978 federal review of the evidence behind 21 different procedures included an informal statement that the consensus at that time was that 10%-15% of medical interventions had scientific support. In 1979, Robert Mendelsohn, MD, published his Confessions of a Medical Heretic. The book became a best-seller, exposing data on the shadow side of conventional medicine's personna. David Eddy's systematic work in revealing this under-belly, to awaken medicine from its dream, dates to the mid-1980s when he coined the EBM phrase.

For decades, leaders of the CAM-IM movement -- including many of the consumers who have rallied to create new healthcare options -- have been aware of, and moved by, medicine's Big Lie. My own reform instincts were early provoked by medicine's two-faces. One example: In 1988, while a vice president with Bastyr University, I crafted and sent out a press release, based on literature review work of Michael Murray, ND, lambasting the routine use of myringotomy, the surgical placement of drainage tubes in (usually) children's ears. A sub-heading in the May 29, 2006 Business Week feature, 18 years later: "Leave Those Ears Alone."

Yes, "they" should have listened to us back then. Now, in the context of nominal unity called "integration," we have a more important question: Through what not yet practiced coalitions - or perhaps not even imagined coalitions - will we finally figure out how to respond effectively to this evidence?

Failing such new political-economic coalitions, we can be sure that a 2015 issue of Business Week will give us a new and shocking report of these economic determinants of our health.

(Thanks to Rita Benn, PhD, for bringing this article to my attention.)